03010032 CITY OF CUPERTINO
BUILDING DIVISION PERMIT 'GONTRACTORINFORMATION:,.
BUILDING ADDRESS: WATER HEATERS ONLY PERMIT NO.
21884 BYRNE CT 03010032
OWNER'S NAME: 970 E. MAIN ST, SUITE 200 APPLICATION SUB DATE
SMITH MARCIE L 01/07/2003
soHONE: (415) 566-2209 SANITARY NO. CONTROL NO.
ARCHITEC(ENGINEER: - BUILDING PERMIT INFO
BLDG ELECT PLUMB MICH
00 LICENSED CONTRACTOR'S DECLARATION
uz P I herehy affirm drat I an licensed under provisions of Chapter 9(commerwing Job Description
�_ with Section 7tlgBaf Diviann Sof Ne Busineaand Professions Code,and my license is
= mfullfnocenJeff Licasi
REPLACE WATER HEATER �BgaB�®
ZC}�j? Liccnu Clas ��1 !b
04p 0 Dare a��3f Cnnlraclnr
k-¢ ARCHITECTS DECLARATION -
a I understand my Plans shall W used as public records
otoG JAN' 1 5 2003
ora Licensed Professional
t-u. OWNER-BUILDER DECLARATION
u� Y 1 hereby affirm Nat I am exempt from the Contractor's License Law for the
BUILDING
w-p 0 following mouth,(Section 7031.5,Business and Professions Calc:Any city or county
,,S:00
'K 2 P which requires a permit to construct,a er,improve,demolish,or repair any structure
Npd.,to its issmrme.also mquims theapplicadr for such permit to file a signedamlement
z< that he is licensed pursuant to fine provisions of the Contractor's License Law(Chapter 9 Sq. Ft. Floor Area $V410tion
I-$ (commencing with Second 7")of Division 3 of the Business and Professions Code)or
-
that Zia exempt therefrom and the bass for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of be Occupancy Type
not more than Five hundred delta.($501y.
❑I.as owner of the property,or my employees with wagesss their sole compensation, 582 F11 13 Ea;IERay
will do the work,and the structure is not intended or offered for sale(Sec.704,1,Business
506 - GAS TE uire ns ecttons
and Professions Code:The Contractor's License Law does not apply lf an owner of p
propeny who W ills or improves thereon.and whodoev sato work himself orthrough his
own employees,provided that such improvements are not intended or offered for sole.If, 507 — FINAL PLUMBING
however.the building or improvement is sold within one year of completion,the nwner-
builder will have the burden of proving that he did not Wild or improve for purpose of
salt.).
❑1,as owner of the properly,em exclusively contracting with licensed convectors to
conswct Ne project(Sec.704,1,Business and Professions Code:)The ConOeemr's Li.
cense law does not apply to an owner of property who Wilds or improves Hereon,and
who contracts for such pmjecm with a contractor(s)licensed pursuant to the Contractor's
License Law.
Cl I on exempt under Sec. .B&P C for this
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following decimations:
I have and will andrown a Certificate of Conserv to self-imon.for Worker'sComped-
sation,as provided for by Second 37M of ft Labor Code,for the performance of the
w rk for which this permit is issued.
1 have and will maintain Workeri Compensation Insure.¢,u required by Section
71.)of the Labor Cade,for the performance of the work for which Nis permit is issued.
My Worker's yCompensation Insurance carrier and Polity number are:
y f r(.a_s1Li Policy Na.:I I_RS(L 2 3
Carrier._ �.
CERTIFC OMPE SATIONIONFROM WORKERS'
COMPENSATION INSURANCE
This section need not be completed if the permit is for one hundred dello.(8100)
or ort.)
1 certify Nat in the performance of the work for which this permit is issued,I Nall not
employ any person in any manner so as to become subjeeuo the Workers'Compensation
laws of California.Dow
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
become subjem to the Warkeh Compassed..provisions of the Labor Code,you...in
OO forthwith comply with such provisions or this permit shall te deemed revoked.
V) CONSTRUCTION LENDING AGENCY
[r I hereby ifirm that there is a con0ruction lending agency lin the performance of
the work for which this permit is issued(Sec.311?7,Ci,C.)
GQ Lendiex N.
.7. z Lender's Addmas
U C I cenify that I have read Nis application and some that Ne above information is
fL — correct.l a gree to comply with all city and county ordinances and alone laws relating to '
QU building construction.and hereby authorize reposenutivea of this city to enter upon the
�U above-mentioned property for impaction purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
to) liabilities,judgments,coats and expenses which may in any way accmc againsuaid City '
7 in consequence of the granting of this permit.
F7 APPLICANT UNDERSTAN�S.(ND WILL COMPLY WITH ALL NONPOINT Issued by: Date
SOURCE REGULATIONS \` /J t,
�T3 Re-roofs
Signature of ApplicaMConuamor are
HAZARDO SMAIgRIALSDISCLOSURE Type of Roof
Will theapplicantor fMunibuilding
e.occupant Chapter 9.12.
handle hanrdousmetrial
az de0netl by the Cupertino Municipal Code.Chapter 9.12,and the Hcahh and Safety
Code,Secti.n 255320)? �_ All roofs shall be inspected prior to any roofing material being installed.
❑Ycs
Will the applicant or future building occupant use equipment ordevicis which If a roof is installed without first obtaining an inspection,I agree to remove
mit hazardous air conmminamts u define y the Bay Arca Air Quality Management all new materials for inspection.
Disuin?
❑Ycs
1 have mad the hazardous materials mquircmcnm under Cooper 6.95 of the Califor-
nia I Italth as Safety Code,Sections 255(15.25533 and 25534.1 understand that if the building
does not currently have a mnam.Nm it is my resperaihihly to notify Ibe rccupan of to
roquiremensw ' uebe me(pri missuanceoI CCNFicamoU, cy. Signature of Applicant Date
/ 7 s
owner er aamerir dagtm Dam All roof coverings to be Class "B" or better